AMERICAN YOUTH FOOTBALL

Participant Forms
REQUIRED FOR REGIONAL AND NATIONAL PARTICIPATION

Participant forms must be presented to the Coach or Team Administrator for

inclusion in the team book. Team books must be presented for compliance
verification prior to participation in any American Youth Football, Inc., American
Youth Cheer dba, Regional, National sanctioned event.
All rostered Participants must complete the following paperwork in order to be allowed to
participate in any American Youth Football, Inc., American Youth Cheer dba, Regional, National
sanctioned event.
Image Release - MINOR
Waiver and Release of Liability - MINOR
Emergency Medical Treatment, Consent and Information Form
Proof of AGE - (see association official for acceptable document
NOTE: - All-American Division (grade based) Required Documentation
Report Card - Please HIGHLIGHT Division / Grade attending
All rostered Participants must receive Medical Clearance in order to be allowed to participate in
any American Youth Football, Inc., American Youth Cheer dba, Regional, National sanctioned
event. Please use the following form if you have not already supplied an acceptable medical
clearance to your team.
Medical Clearance Form
Participant Medical Clearance will become void in the event of an Injury, Accident, or Illness
attended to by a licensed medical professional. The Resume Participation Medical Clearance
must be signed by the attending medical professional in order for the participant to resume
active participation. The signed form must be presented to the American Youth Football, Inc.,
American Youth Cheer dba, Regional, National event official.
Resume Participation Medical Clearance Form
Some form of Participant Photo Identification system must be employed by your Association. If
none was used the following forms can substituted, and is preferred for the American Youth
Football, Inc., American Youth Cheer dba, Regional, National sanctioned events.
Official Participation Tracking and ID Card
Any form / document used for your local Association / Conference must be reviewed by your local council to insure
it's compliance with all of your state and local statutes. AYF makes no representation or warrantee that any of these
conditions have been met.

AMERICAN YOUTH FOOTBALL

Image Release MINOR
ASSOCIATION NAME -

PEDIGREE DAWGS

READ BEFORE SIGNING

In consideration of (insert child's name)
, my minor
child/ward being allowed to participate in any way, in the American Youth Football, Inc.
("AYF") (dba American Youth Football and American Youth Cheer,) national championships
and any other official AYF events and activities, the undersigned agrees that American
Youth Football Inc., is hereby granted the unrestricted right and permission, free from
approval or review, to copyright and/or use my child's/ward's likeness in all media now or
hereafter known, including but not limited to, pictures and videos of my child which he/she
may be included intact or in part for promotion or other commercial use.

Print Name of Parent/Guardian: _______________________________________________

Parent/Guardian Signature:________________________ Date Signed:________________

AMERICAN YOUTH FOOTBALL

Waiver and Release of Liability - Minor
ASSOCIATION NAME - PEDIGREE DAWGS
READ BEFORE SIGNING

IN CONSIDERATION OF_______________
, my child/ward, being allowed to participate in
the American Youth Football American Youth Cheer Regional/National Championships, and or the football and or
cheer programs of ______________________________________________________________, the Local
Organization, which is a legally distinct and organization not operated or controlled by American Youth Football,
despite its membership with American Youth Football, Inc. the undersigned acknowledges and agrees that:
1) The risk of injury to my child/ward, myself, from the activities involved in these programs is significant, including the
potential for permanent disability, paralysis and death, and while particular rules, equipment, and personal discipline
may reduce this risk, the risk of serious injury does exist; and,
2) FOR MYSELF, SPOUSE, AND CHILD/WARD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both
known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume
full responsibility for child/ward, participation; and,
3) I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I
observe any unusual significant concern in my child/wards', readiness or, hazard during my presence or
participation, and/or in the program itself, I will remove my, child/ward, from participation and bring such to the
attention of the nearest official immediately; and,
4) I, for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of
kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS American Youth Football, Inc.(AYF), the local
organization, their respective officers, directors, officials, volunteers, agents, and/or employees, other participants,
sponsoring agencies, tournament host, sponsors, advertisers, and if applicable, owners and lessors of premises used to
conduct the event ( RELEASEES ), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or
damage to person or property, incident to my child/wards', involvement or participation in these programs, WHETHER
ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, TO THE FULLEST EXTENT
PERMITTED BY LAW.
5) I, for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of
kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my
child/ward's involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the
fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY
SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Print Name of Parent/Guardian: _____________________________________________________________

Parent/Guardian Signature:_____________________________ Date Signed: _______________________

UNDERSTANDING OF RISK
I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for
adhering to rules and regulation, and accept them as a participant.
Print Participant s Name: __________________________________________________________________

Participants Signature:_________________________________ Date Signed: _______________________

NOTE: This form as with any and all forms used by your Association should be reviewed by your local counsel for
compliance with any state or local statutes. This form should be kept on file for a minimum of 7 years, longer in the
event of an injury. Please confer with your local attorney for advice as to the appropriate maintenance and storage
term for this and all such forms.

Emergency Medical Treatment, Consent and Information

The following information will be used in the event that a parent / legal guardian is not available. The purpose of this
information is to provide a quick reference for medical personnel should the need arise. Please fill out this form
completely. If a particular question is not applicable write "none", n/a, or other appropriate comment otherwise none will
be assumed. If additional space is needed, please use the back of this form. All information disclosed here will be
treated as confidential. It will be the responsibility of the parent/legal guardian to notify the participants coach and
league/event officials if any information needs to be added, deleted, changed, or updated in any way.
ATHLETE INFORMATION

Nick Name:
City:

Athlete's Name:
Address:

Phone: ( )
State:
Zip:

PARENT OR GUARDIAN INFORMATION

Father's Name:
Address:
Hm Phone: (
)
Employer:

City:
Daytime Phone: (

Mother's Name:
Address:
Hm Phone: (
)
Employer:

City:
Daytime Phone: (

Guardian's Name:
Address:
Hm Phone: (
)
Employer:

City:
Daytime Phone: (

State:

Zip:

State:

Zip:

State:

Zip:

State:

Zip:

Email:

Email:

Email:

FAMILY MEDICAL INSURANCE

Carrier:
Policy #:
Policy Holder Name:
Family Physician's Name:
Dr's Address:
Phone: (
)

Group:
Group #:

City:
Fax: (

Email:

EMERGENCY MEDICAL INFORMATION

Preferred Hospital(s):
EMERGENCY CONTACT:
Phone: (
)
Relationship:
Please list any medical conditions (allergies, asthma, etc.) And medications being taken by the participant named
above. Please list any other information you may deem relevant, and helpful to emergency medical personnel: (please
note if no information is given and the words "none" or "n/a" is not filled in then, "none" will be assumed.

Allergies:
Medical Conditions:
Other:
*I as evidenced below hereby grant permission for my child/ward to participate in any and all,
_______________________________ (Association name) and, American Youth Football, Inc. program(s) event(s),
including but not limited to, athletic, social and/or fundraising activities. I further consent to the administration of any and all
medical treatment necessary to stabilize and or treat any medical condition or medical emergency to which my child/ward
is afflicted. I understand that this authorization is given prior to the need for medical care, but given in advance to avoid
any unnecessary delay in emergency treatment which the attendant and/or medical professional may deem advisable in
the exercise of their best judgment.

*Print Parent/Legal Guardian Name

*Signature Parent/Legal Guardian

*Date

The original Emergency Medical Treatment, Consent and Information form should travel with the coach and a copy should be
kept at the administrative office of the sports organization. Due to privacy concerns, completed forms should be stored in a
secure location with access restricted to those on a need to know basis for the purpose of medical care.

AMERICAN YOUTH FOOTBALL

Medical Clearance Form
ASSOCIATION NAME - PEDIGREE DAWGS
Medical Clearance Form - Must be dated after January 1st of the Current Season

I, as evidenced by my name and signature below, do certify that I am licensed MD and or DO in the
state of ________________________and am qualified in determining that:
(Childs Name:)
______________________is
physically fit and I have found no medical or observable conditions which would contra-indicate his/her
from participating in youth flag football, tackle football, cheer, dance, step or athletic activities.
I am therefore clearing this individual for athletic participation.
Please Print - or - Use Office Stamp Here:

Signature:

Date:

Print Name Clearly:

( Must be dated after January 1st, of the Current Season )

Office Address:

PLEASE NOTE: If this Medical Clearance is voided by injury, accident, or illness, it will be the
responsibility of the Parent/Legal Guardian to notify the participants Coach and League Officials. It will
also be the responsibility of the Parent / Legal Guardian to obtain WRITTEN permission from his/her
physician (either MD or DO) to resume participation. A "Doctors Resume Participation Medical
Clearance Form" is available from the league or you may have the doctor supply his/her own WRITTEN
Clearance as long as it is on the doctor's official stationary and includes the following statement:
"(Participants Name) is physically fit and I have found no medical or observable conditions which would
contra-indicate him/her from participating in youth flag football, tackle football, cheer, dance, step or
athletic activities. I am therefore clearing this individual for athletic participation.
This statement must be supplied by the physician attending to the injury, accident, or illness.

NOTE: This form as with any and all forms used by your Association should be reviewed by your local counsel for
compliance with any state or local statutes. This form should be kept on file for a minimum of 7 years, longer in the
event of an injury. Please confer with your local attorney for advice as to the appropriate maintenance and storage
term for this and all such forms.

AMERICAN YOUTH FOOTBALL

Resume Participation Medical Clearance Form
ASSOCIATION NAME -

PEDIGREE DAWGS

RESUME PARTICIPATION MEDICAL CLEARANCE FORM IS REQUIRED TO RESUME

PARTICIPATION OF ANY KIND AFTER ORIGINAL MEDICAL CLEARANCE IS VOIDED BY
AN, INJURY, ACCIDENT, OR ILLNESS.
I, as evidenced by my name and signature below, do certify that I am licensed MD or DO in the state of
______________________ and am qualified in determining that:
(Childs Name:)
______________is physically fit
and I have found no medical or observable conditions which would contra-indicate him/her from
RESUMING participating in youth flag football, tackle football, cheer, dance, step or athletic activities. I
am therefore clearing this individual for athletic participation.

Please Print - or - Use Office Stamp Here:

Signature:

Print Name Clearly:

/
Date:

/
Office Address:

PLEASE NOTE: If this Resume Participation Medical Clearance is voided by injury, accident, or illness, it
will be the responsibility of the Parent/Legal Guardian to notify the participants Coach and League
Officials. It will also be the responsibility of the Parent / Legal Guardian to obtain WRITTEN permission
from his/her physician (MD or DO) to resume participation. A new "Doctors Resume Participation
Medical Clearance Form" is available from the league or you may have the doctor supply his/her own
WRITTEN Clearance as long as it is on the doctor's official stationary and includes the following
statement: "(Participants Name) is physically fit and I have found no medical or observable conditions
which would contra-indicate him/her from RESUMING participating in youth flag football, tackle football,
cheer , dance, step or athletic activities. I am therefore clearing this individual for athletic participation.
This statement must be supplied by the physician attending to the injury, accident, or illness.

This form can be modified or substituted ONLY to comply with local and/or state laws or due to
medical practitioner regulations.

NOTE: This form as with any and all forms used by your Association should be reviewed by your local counsel for
compliance with any state or local statutes. This form should be kept on file for a minimum of 7 years, longer in the
event of an injury. Please confer with your local attorney for advice as to the appropriate maintenance and storage
term for this and all such forms.

AMERICAN YOUTH FOOTBALL

Participation, Tracking and ID Card - All-American Division
ASSOCIATION NAME - PEDIGREE DAWGS
A
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ASSOCIATION NAME

PLACE PHOTO / DMV / MILITARY ID

CARD HERE

DIVISION OF PLAY - TEAM NAME

PARTICIPANT NAME

JERSEY #

Grad
e

AGE (12/31)

PARTICIPANT PARENT/GUARDIAN NAME

HOME PHONE

WORK PHONE

CELL PHONE

I, Hereby, With My Signature, Do Certify That The Information Below Has Been Collected And Verified By The Means, As A
Minimum, As Instructed In The AYF National Rulebook And/Or Operations Manuel, Current Version.

OFFICIAL PLAYER CERTIFICATION

Conference Verification Signature/STAMP
DATE OF BIRTH:

Age As of
12 / 31

GRADE / AGE
CERTIFICATION

LEAGUE USE ONLY

PARTICIPANT
CONTRACT

MEDICAL
CLEARANCE

Association Verification Signature/STAMP

WAIVER/
RELEASE

EMERGENCY
MEDICAL /
CONsSENT

SCHOLASTICS

Month / Day / Year

GAME DATE PLAYER CHECK

R JAMBOREE
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Week 1

CODE

GAME DATE PLAYER CHECK

Week 11
Week 12

Week 2

Week 13

Week 3

Week 14

Week 4

Week 15

Week 5

Week 16

Week 6

CODE

Week 17

Week 7

Week 18

Week 8

Week 19

Week 9

Week 20

Week 10

Week 21

INSTRUCTIONS: PLAYER CHECK Will Enter Date, Verify The Identity, Of Each Participant, Initial Each Participant Card,
CODE: OK = Everything Verified, I = Sick/Injured, A = Absent / Dropped
ALL MUST BE CHECKED IN / VERIFIED PLAYING OR NOT / ENTER DETAIL UNDER CODE

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Participation Contract, Tracking and ID Card - Page 2

Last Name

First Name

Street Address

City / Town

Date Of Birth (M/D/YR)

Grade in Fall

Initial

State

Age as of 12/31

Zip Code

Parent/Guardian First Name

School in Fall

Medical Insurance (circle one)

Preferred (nick) Name

School Phone

Home Phone

Parent/Guardian Last Name

Home Email Address

Name Of Insurance Carrier

Policy #

YES / NO
Football:

Cheer:

--CHECK ONE --

Registration Fee: $

Check# Cash:

GRAY AREAS FOR OFFICIAL USE ONLY !!

Association:

Division:
Jersey Number Assigned:

Team:

Equipment / Uniform Issued

Returned

PERMISSION TO PARTICIPATE

I acknowledge that I am fully aware of the potential dangers of participation in any sport
and I fully understand that participation in football, cheerleading, dance and/or step may result in SERIOUS INJURIES,
PARALYSIS, PERMANANET DISABILITY AND/OR DEATH. Furthermore, I fully acknowledge and understand that
protective equipment does not prevent all participant injuries. I, the parent/guardian of the above-named participant, do
hereby give my approval for my child/ward to participate, and further assert that I have verified with my child/wards
physician, and in my opinion, my child/ward is physically fit and can participate without limitation in any and all Local,
Regional, National, League/Conference, Association and team/squad activities, including transportation to and from the
activities by a licensed driver.
Initial:

SCHOLASTIC FITNESS

I am of the opinion that my son/daughter/ward is scholastically fit and would benefit by participation in this program. I
agree to submit a copy of my son/daughter/ ward's last completed grade, end of year/last complete report card or a
written statement of scholastic fitness from the school administration.
Initial:

HELMET WAIVER (for football participants)

We acknowledge, AND WE understand the risks involved in my CHILD/WARD, my playing FOOTBALL, which is a
collision sport; the NOCSAE committee has adopted the following warning to be read by, and signed by, both the
parent/guardian and participant. DO NOT USE THIS HELMET TO BUTT, RAM OR SPEAR AN OPPOSING PLAYER,
THIS IS IN VIOLATION OF FOOTBALL RULES AND CAN RESULT IN SEVERE HEAD, BRAIN OR NECK INJURY,
PARALYSIS OR DEATH AND POSSIBLE INJURY TO YOUR OPPONENT, THERE IS A RISK THAT THESE
INJURIES MAY ALSO OCCUR AS A RESULT OF AN ACCIDENTAL CONTACT WITHOUT INTENT TO BUTT, RAM
OR SPEAR, NO HELMET CAN PREVENT ALL SUCH INJURIES.
EQUIPMENT UNIFORM RESPONSIBILITY

Parent/Guardian Initial:

Player Initial:

I assume full responsibility for any and all equipment/uniforms loaned to my child/ward and I agree to promptly return,
upon request, the uniform and other equipment in as good condition as when received except for normal wear and tear.
If I fail to adhere to this policy, I will be responsible for and promptly pay the replacement cost of such equipment.
Initial:

CODE OF CONDUCT

The Ideology Of Youth Sports Including This Program Is To Promote Good Understanding And Fundamental Knowledge Of The
Sport. It Is Also Critical That Good Sportsmanship Including The Ability To Always Conduct Oneself In An Appropriate Manner Of
Positive Accord Both On And Off The Field. It Is Understood That Any Incident Considered Detrimental To The Pursuit Of This
Ideology Will Not Be Tolerated. It Will Be Addressed In Accordance With The Statutes Of The Association, Conference, Current
National Affiliation, State and Local Laws, And May Result In Dismissal From The Program And The Inability To Participate In
Any Future Related Activities Of The Association. This Code Of Conduct Applies To All Involved With The Program Including But
Not Limited To, The Football Players, Cheerleaders, Spirit Participants, Parents And Guardians.
Initial:

PRINT Parents/Guardian Name:

Parents/Guardian Signature:

Date Signed:

NOTE: This form as with any and all forms used by your Association should be reviewed by your local counsel for
compliance with any state or local statutes. This form should be kept on file for a minimum of 7 years.

AMERICAN YOUTH FOOTBALL

Participation, Tracking and ID Card - National Division
ASSOCIATION NAME - PEDIGREE DAWGS
A
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ASSOCIATION NAME

PLACE PHOTO / DMV / MILITARY ID

CARD HERE

DIVISION OF PLAY - TEAM NAME

PARTICIPANT NAME

JERSEY #

AGE (7/31)

O/L WEIGHT

PARTICIPANT PARENT/GUARDIAN NAME

HOME PHONE

WORK PHONE

CELL PHONE

I, Hereby, With My Signature, Do Certify That The Information Below Has Been Collected And Verified By The Means, As A
Minimum, As Instructed In The AYF National Rulebook And/Or Operations Manuel, Current Version.

OFFICIAL PLAYER CERTIFICATION

Conference Verification Signature/STAMP
DATE OF BIRTH:

Age As of
Age Cut off Date

Month / Day / Year

CERTIFICATION
WEIGHT

G
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Week 1

PARTICIPANT
CONTRACT

MEDICAL
CLEARANCE

CODE

WAIVER/
RELEASE

EMERGENCY
MEDICAL /
CONsSENT

GAME DATE WEIGH MASTER

SCHOLASTICS

CODE

Week 11
Week 12

Week 2

Week 13

Week 3

Week 14

Week 4

Week 15

Week 5

Week 16

Week 6

Association Verification Signature/STAMP

Older/Lighter:

GAME DATE WEIGH MASTER

R JAMBOREE
E

LEAGUE USE ONLY

Week 17

Week 7

Week 18

Week 8

Week 19

Week 9

Week 20

Week 10

Week 21

INSTRUCTIONS: Weigh Master Will Enter Date, Verify The Identity, Weight, Of Each Participant, Initial Each Participant Card,
CODE: OK = Everything Verified, ENTER WEIGHT = Over Weight, I = Sick/Injured, A = Absent / Dropped
ALL MUST BE CHECKED IN / VERIFIED PLAYING OR NOT - IF OVERWEIGHT ENTER THE WEIGHT UNDER CODE

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Participation Contract, Tracking and ID Card - Page 2

Last Name

First Name

Street Address

City / Town

Date Of Birth (M/D/YR)

Grade in Fall

Initial

Age as of 7/31

Medical Insurance (circle one)

State

Weight

School in Fall

Preferred (nick) Name

Zip Code

Parent/Guardian First Name

School Phone

Home Phone

Parent/Guardian Last Name

Home Email Address

Name Of Insurance Carrier

Policy #

YES / NO
Football:

Cheer:

--CHECK ONE --

Registration Fee: $

Check# Cash:

GRAY AREAS FOR OFFICIAL USE ONLY !!

Association:

Division:
Jersey Number Assigned:

Team:

Equipment / Uniform Issued

Returned

PERMISSION TO PARTICIPATE

I acknowledge that I am fully aware of the potential dangers of participation in any sport
and I fully understand that participation in football, cheerleading, dance and/or step may result in SERIOUS INJURIES,
PARALYSIS, PERMANANET DISABILITY AND/OR DEATH. Furthermore, I fully acknowledge and understand that
protective equipment does not prevent all participant injuries. I, the parent/guardian of the above-named participant, do
hereby give my approval for my child/ward to participate, and further assert that I have verified with my child/wards
physician, and in my opinion, my child/ward is physically fit and can participate without limitation in any and all Local,
Regional, National, League/Conference, Association and team/squad activities, including transportation to and from the
activities by a licensed driver.
Initial:

SCHOLASTIC FITNESS

I am of the opinion that my son/daughter/ward is scholastically fit and would benefit by participation in this program. I
agree to submit a copy of my son/daughter/ ward's last completed grade, end of year/last complete report card or a
written statement of scholastic fitness from the school administration.
Initial:

HELMET WAIVER (for football participants)

We acknowledge, AND WE understand the risks involved in my CHILD/WARD, my playing FOOTBALL, which is a
collision sport; the NOCSAE committee has adopted the following warning to be read by, and signed by, both the
parent/guardian and participant. DO NOT USE THIS HELMET TO BUTT, RAM OR SPEAR AN OPPOSING PLAYER,
THIS IS IN VIOLATION OF FOOTBALL RULES AND CAN RESULT IN SEVERE HEAD, BRAIN OR NECK INJURY,
PARALYSIS OR DEATH AND POSSIBLE INJURY TO YOUR OPPONENT, THERE IS A RISK THAT THESE
INJURIES MAY ALSO OCCUR AS A RESULT OF AN ACCIDENTAL CONTACT WITHOUT INTENT TO BUTT, RAM
OR SPEAR, NO HELMET CAN PREVENT ALL SUCH INJURIES.
EQUIPMENT UNIFORM RESPONSIBILITY

Parent/Guardian Initial:

Player Initial:

I assume full responsibility for any and all equipment/uniforms loaned to my child/ward and I agree to promptly return,
upon request, the uniform and other equipment in as good condition as when received except for normal wear and tear.
If I fail to adhere to this policy, I will be responsible for and promptly pay the replacement cost of such equipment.
Initial:

CODE OF CONDUCT

The Ideology Of Youth Sports Including This Program Is To Promote Good Understanding And Fundamental Knowledge Of The
Sport. It Is Also Critical That Good Sportsmanship Including The Ability To Always Conduct Oneself In An Appropriate Manner Of
Positive Accord Both On And Off The Field. It Is Understood That Any Incident Considered Detrimental To The Pursuit Of This
Ideology Will Not Be Tolerated. It Will Be Addressed In Accordance With The Statutes Of The Association, Conference, Current
National Affiliation, State and Local Laws, And May Result In Dismissal From The Program And The Inability To Participate In Any
Future Related Activities Of The Association. This Code Of Conduct Applies To All Involved With The Program Including But Not
Limited To, The Football Players, Cheerleaders, Spirit Participants, Parents And Guardians.
Initial:

PRINT Parents/Guardian Name:

Parents/Guardian Signature:

Date Signed:

NOTE: This form as with any and all forms used by your Association should be reviewed by your local counsel for
compliance with any state or local statutes. This form should be kept on file for a minimum of 7 years.

AMERICAN YOUTH FOOTBALL

Absentee Form
ASSOCIATION NAME -

PEDIGREE DAWGS

1) Name of Child:
[ ] National, [ ] All-American (Check One)

2) Football Class / Division:

ie: Jr. PeeWee, PeeWee, ..

[ ] Blue Level, [ ] Red Level (Check One)

[ ] Small (5-17), [ ] Large (18-36) (Check One)

3) Spirit Class / Division:

ie: 10 Under,11 Under, ...

4) Program Type:
ie: Football, Cheer, Dance, Step ...

5) Team Name:
Local Event

6) Event Affected:

State Event

Regional Event

National Event

Other

(Check all that apply)

7) Reason Unable to Participate (check one):

Medically Related

(Attach doctor's note)

Scholastically Related

(Attach teacher's note)

Family Obligation

(Please explain below)

Other

(Please explain below)

Waivered Player

(Please Attach Waiver)

8) Explanation:

9) By our signatures below, we attest that the information provided herein is true to the best of
our belief.
Parent/Guardian:

Date:

Head Coach:

Date:

Association Official:

Date:

IMPORTANT MESSAGE FOR THE COACH:

All rostered Participants must be accounted for. This form is to be used for participants that, for
whatever reason, will not participate with their team at the Regional or National event. This form
(and any attachments) must be in your Participant / Roster book at the competition checkin/event site. If Participants are found to have been told to stay home, bullied, or in any other way
discouraged from joining the team in an effort to build a stronger team the Head Coach and the
Association will be subject to suspension and a forfeit of any game played at a Region or National
event.